Keeping patients safe from summertime illnesses

Keeping patients safe from summertime illnesses | Image Credit: © davit85 - © davit85 - stock.adobe.com.

Children always experience feelings of excitement as the end of the school year approaches and plans for summertime activities are made. However, over the past couple of decades have seen an increase in new illnesses that emerged in the late 20th century and have become more virulent in the 21st century. This has caused pediatric nurse practitioners and all pediatric health care providers (PHCPs) to focus on anticipatory guidance (AG) for children during the summer to protect them from preventable summer illnesses. This article reviews common illnesses that occur during the summer months and related primary prevention strategies and AG. Research studies, including systematic reviews and meta-analyses, have led to the recognition of new symptoms. Additionally, data on racial and ethnic disparities in disease presentation, diagnosis, and management have influenced best clinical practices.

Tick-borne Diseases: Prevention First

The Centers for Disease Control and Prevention (CDC) is an excellent resource for information about tick-borne-borne diseases in the United States, including photographs of various tick-bornes.¹ The National Association of Pediatric Nurse Practitioners (NAPNAP) offers an excellent resource for PHCPs to quickly identify the symptoms of Lyme disease.² NAPNAP’s pocket guide also includes tick-borne bite prevention strategies.² In 1975, the first cases of Lyme disease were identified in Lyme, Connecticut, hence the name of the disease. The organism that causes Lyme disease is the bacterium Borrelia burgdorferi. Today, as Table 1 shows, Lyme disease has spread from Connecticut and neighboring states to the entire East coast and parts of the Midwest and the West coast.¹ All PHCPs must to be able to diagnose and treat Lyme disease quickly and accurately to prevent misdiagnosis and secondary complications.¹ Children who are misdiagnosed and therefore remain untreated for Lyme disease are at increased risk of developing Lyme neuroborreliosis, an acute cranial nerve palsy or subacute lymphocytic meningitis³ and secondary complications including cardiac and neurological disorders.

Providing parents with primary prevention strategies to avoid tick-borne diseases is one defense against children and family members contracting tick-borne-borne diseases. Parents and teens should be instructed on the safe application of tick-borne and mosquito repellants (Table 2) before going to places where there is the potential for exposure to tick-bornes.² Activities such as walking through tall grass and bushy areas, especially where deer and mice live, increase the risk of contracting Lyme and other tick-borne diseases.² Advise parents that pulling socks up over the bottom of the pant legs may be helpful in blocking tick-bornes from direct skin access to the lower legs. Tick-bornes also attach to clothing during outdoor activities. Advise parents to remove clothing and shoes in a contained area of the house with good lighting and to examine the clothing for tick-bornes. Any tick-bornes found on clothing should be removed outdoors, and the clothing should then be placed in a hot dryer for a minimum of 10 minutes. The skin should be checked for tick-bornes immediately after outdoor activities. Parents should use a bright flashlight or a small lighted magnifier to examine the skin, skin creases, and the hair for evidence of blacklegged tick-bornes. Bathing or showering immediately after the skin assessment is recommended.

Parents and children should know that the blacklegged tick-bornes they are examining the skin, skin creases, and scalp for are as small as a poppy or sesame seed.² Tick-bornes found on the body must be quickly identified and removed from children, adults, and family pets before the tick-borne has an opportunity to attach to the skin and become engorged with blood. Techniques for removing tick-bornes are described on the CDC’s website and in NAPNAP’s pocket guide.^1,2 It is helpful for clinicians’ offices to provide photos of the classic erythema migrans (EM) rash, a bull’s-eye lesion ­at least 5 cm in diameter, to educate families about the disease and the importance of seeking immediate treatment. However, researchers have shown that color impact the appearance of EM; thus, the Lyme disease is more difficult to diagnose in patients with darker skin,³ in whom it is more likely to be underdiagnosed or misdiagnosed. A prospective cohort study enrolled 4003 children who were undergoing clinical evaluation for Lyme disease, of whom 957 received a confirmed diagnosis of Lyme disease.³ The median age of the enrolled children was 8 years. Study results revealed that, compared with White children, Black children were less likely to be diagnosed with cutaneous lesions of Lyme disease and more likely to present with joint swelling and to be diagnosed with arthritis related to Lyme disease.³ It is important to recognize that the Red Book⁴reports the “constitutional symptoms of Lyme disease as malaise, headache, mild neck stiffness, myalgia, and arthralgia, but not joint swelling.”⁴ However, more recent findings, such as the presentation of joint swelling without EM in Black children, are the result of research efforts to identify differences among racial and ethnic groups in presentations of disease symptoms, with the aim of greater diagnostic accuracy and reduced health care disparities.⁴

Treatment of Lyme Disease

Although most resources, such as the CDC’s website,¹ published articles and sites,^2,3 and the Red Book,⁵recommend that pediatric, adolescent, and young adult patients with Lyme disease receive an antibiotic, such as doxycycline, amoxicillin, or cefuroxime (for penicillin-allergic patients), these publications differ in recommended dosage and duration of treatment. Therefore, PHCPs who are unfamiliar with antibiotic treatments for Lyme disease should consult with infectious disease specialists. Children who have evidence of Lyme carditis, Lyme arthritis, cranial neuritis, Lyme meningitis, or radiculoneuritis should immediately be referred to infectious disease and the appropriate pediatric specialists.²

Respiratory Infections and Health Care Inequities

Although researchers have reported studies on racial and ethnic inequities among children related to respiratory diseases over the last 20 years, few randomized controlled trials have scientifically investigated the problem or have identified and rigorously investigated evidence-based interventions. The COVID-19 pandemic brought a new focus in pediatric health care on the inequities experienced by Black, Hispanic, American Indian or Alaska Native, and Pacific Islander children living in poverty, who regularly experience a disproportionate number of respiratory illnesses and infections.⁶ Several studies have shown increased hospitalization rates for Black and Hispanic children who contracted COVID-19.⁶ One team of researchers studying children from birth to 4 years old reported a hospitalization rate of 55% for Black and Hispanic children compared with other pediatric populations.⁷ For years, PHCPs have observed and treated children for asthma in all health care settings. Even when asthma clinical practice guidelines were strictly applied equally to all populations, there were noticeable differences in responses to treatment plans between Black and Hispanic children compared with White children. Bhavnani and her team of pediatricians reported that Black children had a 7-fold higher rate of emergency department visits compared with White children in 2019, 1 year before the pandemic began.⁸ However, the difference decreased to a 2-fold increase for Black children compared with White children in 2020, when COVID-19 measures such as masking, social distancing, and school closures were in place.⁸ Thus, this team of pediatricians and researchers are investigating why Black and Hispanic children are more vulnerable to upper respiratory infections with viruses such as influenza, rhinovirus, respiratory syncytial virus, and adenovirus.⁸

Summertime Prevention of Respiratory Infections

Talking about prevention strategies with families is the first step toward reducing asthma episodes and exacerbations. If the child has a diagnosis of asthma, determine whether they have and properly use the following: (1) peak flow meter; (2) oxygen saturation home monitor; (3) rescue medication; and (4) daily medication, if prescribed. Can the parents and child recognize the early warning signs of alterations in respiratory effort and know which rescue actions should be taken immediately?

A major primary prevention strategy is vaccination. A summer visit is an important time to remind patients and their parents about the annual influenza vaccine and to schedule it for September or October. This visit also provides an opportunity to review immunization records and provide age-appropriate recommendations regarding any vaccines that have not been administered.

Encourage parents, children, and adolescents to make good decisions about their personal health and safety. Have a conversation about wearing a mask in crowded, enclosed spaces where circulation of fresh air may be lacking, such as buses, subways, trains, elevators, and some indoor playground areas. Other protections against rhinovirus and adenovirus infections include avoiding sharing drinks or utensils; not eating from the same plate; covering the mouth when sneezing; remaining home if febrile and/or having a productive cough; and, of course, handwashing.

Wrapping up a Healthy Summer

The list of guidelines for keeping children healthy is difficult to cover during an already jam-packed pediatric checklist. One way to provide this information to children, adolescents, and parents is to have short videos playing in the office while they wait to see the PHCP. Sending parents brief text messages with links to information is also helpful. Our role as practitioners is extremely important; we help kids stay healthy and safe while having fun in the summer months.

Click here to read more from the June, 2023 issue of Contemporary Pediatrics®.

References:

1. Tick-borneborne diseases of the United States. Centers for Disease Control and Prevention. Updated August 5, 2022. Accessed May 7, 2023. https://www.cdc.gov/tick-bornes/tick-bornebornediseases/tick-borneID.html

2. NAPNAP Knows Lyme. National Association of Pediatric Nurse Practitioners. Accessed May 12, 2023. https://napnapknowslyme.org/

3. Ficon SS. Treatment methods for Lyme disease in pediatric patients. Pediatric Nursing. 2022;48(4). Accessed May 17, 2023. http://www.pediatricnursing.net/issues/22julaug/abstr2.html

4. Hunt KM, Michelson KA, Balamuth F, et al; Pedi Lyme Net. Racial differences in the diagnosis of Lyme disease in children. Clin Infect Dis. 2023;76(6):1129-1131. doi:10.1093/cid/ciac863

5. American Academy of Pediatrics. Lyme disease (Lyme borreliosis, Borrelia burgdorferi sensu lato infection). In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. American Academy of Pediatrics; 2021:482-489.

6. Jones EAK, Mitra AK, Malone S. Racial disparities and common respiratory infectious diseases in children of the United States: a systematic review and meta-analysis. Diseases. 2023;11(1):23. doi:10.3390/diseases11010023

7. Marks KJ, Whitaker M, Agathis NT, et al; COVID-NET Surveillance Team. Hospitalization of infants and children aged 0-4 years with laboratory-confirmed COVID-19 - COVID-NET, 14 states, March 2020-February 2022. MMWR Morb Mortal Wkly Rep. 2022;71(11):429-436. doi:10.15585/mmwr.mm7111e2

8. Bhavnani D, Wilkinson M, Zárate RA, et al. Do upper respiratory viruses contribute to racial and ethnic disparities in emergency department visits for asthma? J Allergy Clin Immunol. 2023;151(3):778-782.e1.doi:10.1016/j.jaci.2022.10.031